Responsible Office: Office of Cybersecurity
Last Review: 09/24/2020
Next Review: 09/24/2022
Contact: Chris Madeksho
This Standard applies to all UTHSC data and systems; regardless of technology, that transmits, stores, utilizes, or manipulates said data. This standard is applicable to all UTHSC employees, and students, as well as to third-party agents/vendors authorized to access UTHSC data.
Data owner – The person who is ultimately responsible for the data and information being collected and maintained by his or her department or division
Risk – The level of impact on organizational operations (including mission, functions, image, or reputation), organizational assets, or individuals resulting from the operation of an information system given the potential impact of a threat and the likelihood of that threat occurring
Risk Assessment – The process of identifying, estimating, and prioritizing risks to organizational operations (including mission, functions, image, reputation), organizational assets, individuals, other organizations, and the Nation, resulting from the operation of an information system
System owner – Person or organization having responsibility for the development, procurement, integration, modification, operation, and maintenance, and/or final disposition of an information system
Vulnerability – Weakness in an information system, system security procedures, internal controls, or implementation that could be exploited or triggered by a threat source
Chief Information Security Officer (CISO) is responsible for providing guidance and direction in assessment, planning, and implementation of all security standards, practices, and commitments required. This individual is responsible for adherence to this standard.
Security Lead Analyst is responsible for providing security guidance for protection of PII, ePHI, and other sensitive information to the UTHSC community. This role along with the CISO is responsible for the adherence of this policy.
System/Data Owner is responsible for performing the various steps related to identifying potential risks and threats and are required to ensure that identification of risks is properly categorized and documented in terms of their potential threat to their college, department or area. The system and data owner(s) are then responsible to develop the risk mitigation plan and work towards complete mitigation of identified risks. All information regarding risks to the business systems will be the responsibility of the System Data Owner, or appointed delegate, to document, track and respond whenever appropriate.
- All Information Systems must be assessed for risk that results from threats to the integrity, availability, and confidentiality of UTHSC data. Assessments should be completed using the guidelines set forth in RA-001-Risk Assessment prior to purchase of, or significant changes to, an Information System; and at least annually for systems that store, process or transmit data with a classification ranking of 3 in any area per GP-002-Data & System Classification.
- Risks identified by a risk assessment must be mitigated or accepted prior to the system being placed into operation.
- Residual risks may only be accepted on behalf of the university by a person with the appropriate level of authority as determined by the Chief Information Security Officer. Approval authority may be delegated if documented in writing, but ultimate responsibility for risk acceptance cannot be delegated.
- Each Information System must have a system security plan, prepared using input from risk, security, and vulnerability assessments.
- Exceptions to this Standard should be requested using the process outlined in GP-001.02 Security Exceptions and Exemptions to ITS Standards and Practices
- RA-001-Risk Assessment
- GP-002-Data & System Classification
- GP-001.02 Security Exceptions and Exemptions to ITS Standards and Practices